NURSING 230 MIDTERM EXAMINATION (NUR 230) EXAM
QUESTIONS AND ANSWERS
subjective data - ANSWER>>What patient says about himself or herself during
history taking
objective data - ANSWER>>Observed when inspecting, percussing, palpating, and
auscultating patient during physical examination
Database - ANSWER>>formed from these elements, plus patient's record and
laboratory studies
Diagnostic reasoning - ANSWER>>a dynamic thinking process that leads to the
identification of a hypothesis that best explains the clinical evidence
Steps of the Nursing Process - ANSWER>>1. Assessment
2. Diagnosis
3. Outcome Identification
4. Planning
5. Implementation
6. Evaluation
Assessment - ANSWER>>- collect data from multiple sources
- use evidence-based assessment
- document relevant data
Steps of assessment collection - ANSWER>>1. Review of clinical record
2. Interview
3. Health history
4. Physical examination
,5. Functional assessment
6. Cultural and spiritual assessment
7. Consultation
8. Review of the literature
Nursing Process: Diagnosis - ANSWER>>- Interpretation of data by identifying
clusters of cues so as to make inferences
- Compare clusters of cues with definitions and defining characteristics
- Validation of inferences based on findings
- Identify related factors
- Document the diagnosis
Nursing Process: Outcome Identification - ANSWER>>-identify expected outcomes
related to individualization
- ensure outcomes are realistic and measurable
- specify short-term and long-term goal measurement criteria
Nursing Process: Planning - ANSWER>>- establish priorities
- develop outcomes
- set time frames for outcomes
- identify interventions
- utlize other health care members in planning process
- Document plan of care
Nursing Process: Implementation - ANSWER>>- Determine patient readiness and
involve patient(s) in health care process
- Review planned interventions with interdisciplinary health care team members
to facilitate collaborative effort
- Utilize principles of delegation, being mindful of supervision and evaluation
- Counsel person and significant others
- Refer for continuing care
- Document care provided
,Nursing Process: Evaluation - ANSWER>>- Refer to established outcomes
- Evaluate individual's condition and compare actual outcomes with expected
outcomes
- Summarize results of evaluation
- Identify reasons for failure to achieve expected outcomes
- Take corrective action to modify plan of care
- Document evaluation in plan of care
Critical Thinking Principles - ANSWER>>- Proceed through sequential steps from
novice to expert
- Utilize a multidimensional thinking approach to interpret data
>use an organized, systematic assessment format
- Validate and confirm findings based on nonjudgmental interpretation of data
>check and corroborate accuracy and reliability of data
- Cluster data info to support evidence as well as rule out inconsistent clinical
findings in terms of differential diagnosis
>distinguish relevant signs and symptoms
First-level priority problems - ANSWER>>emergent, life-threatening, and
immediate (ex: establishing an airway or supporting breathing)
Second-level priority problems - ANSWER>>next in urgency; require attention so
as to avoid further deterioration
(ex:
Third-level priority problems - ANSWER>>Important to the patient's health but
can be addressed after more urgent health problems are addressed
collaborative problems - ANSWER>>approach to treatment involves multiple
disciplines
, First Step of Problems and Outcomes - ANSWER>>Identify patient outcomes and
delineate measurable goals
Qualify short-term and long-term goals that are realistic and patient centered
Second Step of problems and outcomes - ANSWER>>Include evaluation methods
that will allow for validation of results or adjustments to care planning
Incorporation of planning methods is a critical element in the delivery care
Third step of problems and outcomes - ANSWER>>continuously evaluate the plan
of care
Analyze and implement changes as needed in order to maintain pathway toward
goal achievement
comprehensive plan of care - ANSWER>>- Evaluate and update plan
- Record revised plan and keep it up-to-date
- Communicate revised plans to multidisciplinary team
- Be aware that this is a legal document, and accurate recording is important for
evaluation, insurance reimbursement, and research
collecting 4 types of data - ANSWER>>- Complete total health database
- Episodic/problem-centered database
- follow-up database
- emergency database
Episodic or problem-centered databases - ANSWER>>- for limited or short-term
problems
- collect "mini" database, smaller scope and more focused than complete
database
- concerns mainly one problem
QUESTIONS AND ANSWERS
subjective data - ANSWER>>What patient says about himself or herself during
history taking
objective data - ANSWER>>Observed when inspecting, percussing, palpating, and
auscultating patient during physical examination
Database - ANSWER>>formed from these elements, plus patient's record and
laboratory studies
Diagnostic reasoning - ANSWER>>a dynamic thinking process that leads to the
identification of a hypothesis that best explains the clinical evidence
Steps of the Nursing Process - ANSWER>>1. Assessment
2. Diagnosis
3. Outcome Identification
4. Planning
5. Implementation
6. Evaluation
Assessment - ANSWER>>- collect data from multiple sources
- use evidence-based assessment
- document relevant data
Steps of assessment collection - ANSWER>>1. Review of clinical record
2. Interview
3. Health history
4. Physical examination
,5. Functional assessment
6. Cultural and spiritual assessment
7. Consultation
8. Review of the literature
Nursing Process: Diagnosis - ANSWER>>- Interpretation of data by identifying
clusters of cues so as to make inferences
- Compare clusters of cues with definitions and defining characteristics
- Validation of inferences based on findings
- Identify related factors
- Document the diagnosis
Nursing Process: Outcome Identification - ANSWER>>-identify expected outcomes
related to individualization
- ensure outcomes are realistic and measurable
- specify short-term and long-term goal measurement criteria
Nursing Process: Planning - ANSWER>>- establish priorities
- develop outcomes
- set time frames for outcomes
- identify interventions
- utlize other health care members in planning process
- Document plan of care
Nursing Process: Implementation - ANSWER>>- Determine patient readiness and
involve patient(s) in health care process
- Review planned interventions with interdisciplinary health care team members
to facilitate collaborative effort
- Utilize principles of delegation, being mindful of supervision and evaluation
- Counsel person and significant others
- Refer for continuing care
- Document care provided
,Nursing Process: Evaluation - ANSWER>>- Refer to established outcomes
- Evaluate individual's condition and compare actual outcomes with expected
outcomes
- Summarize results of evaluation
- Identify reasons for failure to achieve expected outcomes
- Take corrective action to modify plan of care
- Document evaluation in plan of care
Critical Thinking Principles - ANSWER>>- Proceed through sequential steps from
novice to expert
- Utilize a multidimensional thinking approach to interpret data
>use an organized, systematic assessment format
- Validate and confirm findings based on nonjudgmental interpretation of data
>check and corroborate accuracy and reliability of data
- Cluster data info to support evidence as well as rule out inconsistent clinical
findings in terms of differential diagnosis
>distinguish relevant signs and symptoms
First-level priority problems - ANSWER>>emergent, life-threatening, and
immediate (ex: establishing an airway or supporting breathing)
Second-level priority problems - ANSWER>>next in urgency; require attention so
as to avoid further deterioration
(ex:
Third-level priority problems - ANSWER>>Important to the patient's health but
can be addressed after more urgent health problems are addressed
collaborative problems - ANSWER>>approach to treatment involves multiple
disciplines
, First Step of Problems and Outcomes - ANSWER>>Identify patient outcomes and
delineate measurable goals
Qualify short-term and long-term goals that are realistic and patient centered
Second Step of problems and outcomes - ANSWER>>Include evaluation methods
that will allow for validation of results or adjustments to care planning
Incorporation of planning methods is a critical element in the delivery care
Third step of problems and outcomes - ANSWER>>continuously evaluate the plan
of care
Analyze and implement changes as needed in order to maintain pathway toward
goal achievement
comprehensive plan of care - ANSWER>>- Evaluate and update plan
- Record revised plan and keep it up-to-date
- Communicate revised plans to multidisciplinary team
- Be aware that this is a legal document, and accurate recording is important for
evaluation, insurance reimbursement, and research
collecting 4 types of data - ANSWER>>- Complete total health database
- Episodic/problem-centered database
- follow-up database
- emergency database
Episodic or problem-centered databases - ANSWER>>- for limited or short-term
problems
- collect "mini" database, smaller scope and more focused than complete
database
- concerns mainly one problem
